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NPI Code Detail

MEDICARE: ELIZABETH MARIE BOURG DPT

MEDICARE: ELIZABETH MARIE BOURG DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical TherapistCP057805TTX
2225100000XPhysical Therapist12012LA

General Provider Information

NPI Number : 1265366199
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELIZABETH MARIE BOURG DPT
Provider Business Mailing Address
First Line : 180 STATE ST STE 225
Second Line :
City : SOUTHLAKE
State : TX
Zip : 76092-7632
Country : US
Telephone Number : 866-525-3175
Fax Number :
Provider Business Practice Location Address
First Line : 180 STATE ST STE 225
Second Line :
City : SOUTHLAKE
State : TX
Zip : 76092-7632
Country : US
Telephone Number : 866-525-3175
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/08/2026
Last Update Date : 06/08/2026

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Directions to “ ELIZABETH MARIE BOURG DPT” Practice Location

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